Tobacco Action Group Meeting 2 Discussion Board
Meeting 2 Notes
Welcome to Meeting 2 of the Comprehensive Tobacco Prevention and Control Action Group!

[NOTE: Comments listed here are based on notes taken during the meeting and may not accurately capture or summarize comments made by participants. Corrections and clarifications are welcomed and should be emailed to Connie Satzler,]

Members Present: Graham Bailey, Lisa Benlon (phone), Mike Fox (phone), Julia Francisco (phone), Carolyn Gaughn (phone), Sarah Gronberg, Jon Hauxwell (phone), Harlen Hays, Mary Jayne Hellebust (phone), Judy Keller, Paula Marmet, Karry Moore, Kelly Peak, Ghazala Perveen, Janel Rose (phone), John Rule, Connie Satzler, Brandon Skidmore

Paula gave overview of HK2010 and Steering Committee progress to-date.

3 workgroups met (see website for workgroup history)
After workgroup reports...3 issues surfaced as generating the most interest among Steering Committee members. Action groups are centered on these 3 issues.

Terri Roberts gave overview at Meeting 1.

Reviewed recommendations proposed from Meeting 1. (See Meeting 1 notes.)

Today: Review progress from last meeting. Add & edit as necessary. Include additional detail with recommendations from last time. Prioritize what we give back to Steering Committee (SC).

SC looking for...state, local, organizational level policy and program initiatives that can be implemented.

Recommendation I - How did you get to 'critical mass' at local level? What was the background of this?

This is the position of the Tobacco Free KS Coalition. It is believed that until we have critical mass at local level, policy makers will be reluctant to implement state-wide initiative.

Why wouldn't the government support regardless of the local community?
Multiple benefits. Why wouldn't she take leadership on this? Piece-mealing may be good. Legislators are more apt to make decisions based on will of people.

Recommend statewide survey...
- Support total?
- Something that excludes bars and rest?
- Ban during certain times/days

Lisa: Our organization has done a lot of study on this...for it to be effective, there needs to be several communities out there. Many more than we have now. Because if it should fail, it would be a long time before leg will take it up again.
Also, I'm not comfortable using survey with different triggers. Our organization supports 100% smoke free - no exceptions. Just my view on it... Also our national view on it, we have to voice this opinion.

This is our feeling also…we don't want to publicly endorse weak laws. We also don't want to survey to legitimize things that we think should not be on the table. Haven't decided what the critical mass is.

Also, think statewide ordinance would fail. If the time came that an assessment of political climate would support, would certainly be preferable to have statewide ordinance vs. piecemeal.

...Don't like piecemeal approach. Would think a survey...would tell us whether or not people would support. Would be comfortable going with all or nothing approach on the survey. We need to stand up and do this if we're going to make KS healthier.

Curious to explore this option more...the purpose of this meeting is to challenge the way we've addressed it in the past...if the group were to start with a massive marketing campaign THEN follow-up with all or nothing, an opportunity to strategically build momentum before we survey, would this change the nature of how this will play out? Have not had statewide smoke-free marketing campaign.

Sure, think this could be part of the process.

As far as public opinion, Harlen is showing us data...54.1% say smoking should not be allowed in restaurants. 70% say it shouldn't be allowed in public shopping malls.

Local level...will have more momentum.

How long are we willing to wait to achieve critical mass and what constitutes critical mass in the first place?

I can go back to my national and see what they consider critical mass, but I don't think we have it now...also concerned with the bill sitting in the house now. Doesn't even have enough votes to get out of committee.

If we could draft legislation and find someone to carry for us, don't have a problem trying it. Our organization has a community readiness form on how much education you need to get out there...we just fear that there isn't enough support.

One of national arguments in not doing statewide to start with is to protect against preemption at local level. The fear is that bill will become weak with 100,000 loopholes, everyone will jump on, but it won't really do anything.

Safer playing field if you have good local organizations across state.

Washington State just passed. Seems to be a good one. We don't have a power base here. How did they do it in Washington State?

They had a lot of money and the government support.

Public opinion typically supports. (See comment posted by Carolyn.)

Let's look at best practices of other states.

I've heard there are quite a few compromised bills out there...

Concerns I've heard have been valid. Want to weight in on advocating statewide piece of legislation. I agree that statewide law won't be passed at this point. Don't think we should advocate for compromise law. On the other hand, I view supporting strong statewide law, at this point a means at which the issue could be amplified to the general public. People willing to testify, media attention...then local leaders may be willing to take on issue. See purpose of promoting statewide legislation - not so much getting it passed, but more as a tool to gain leverage among the public & local communities.

We do have weak local ordinances as well. Same pitfalls apply at local level.

Have had a couple of local places...became aware that statewide bill introduced, then backed off locally.

Yes, we had some at Hays that said this should be the state's responsibility.

Think discussion around statewide ordinance is valuable, but think we would be remiss if we didn't discuss recommendations to put forth to local communities - e.g., tobacco-free school grounds. Give recommendations behind statewide recommendations. Beyond excise tax, etc. Recommend to put forth to local community.

Is there a way to build financial incentives for schools to have smoke-free grounds? Are there incentives for businesses?

Is there an interest for a statewide smoke-free school grounds policy? Was an interest in the 90s, may be more viable to more forward now.

If you combine statewide smoke-free school policy with possibly huge local successes, these two elements may really change the picture for a statewide clean indoor air ordinance.

Department of Education is asking schools to have a Coordinated School Health Plan in place by June 2006.

Could smoke-free campus fit in with this?

Requirements on federal law focused on nutrition and physical activity. When we presented training around the state, we provided the same type of guidelines to schools related to tobacco, nutrition, and physical activity. (Federal, not required to have guidelines for tobacco, but in KS we're recommending.)

Our job has been to show schools how they can advance their policies to improve the health of students, priority in providing incentives for schools to move forward with appropriate policies.

What to recommend to the SC? Options include...
* Marketing campaign
* Use state clean indoor air law to help move forward at local level
* Focus on state law for smoke-free school grounds (or incentives to enact at schools)
* Statewide Survey

Maybe our statement SHOULD be to recommend a statewide clean indoor air ordinance.

Has anyone surveyed legislators on this issue? (not only committee)

Think this...

This concept, if we go back to HK2010, concept of adopting a high standard for our recommendations, even if we're dividing between what is immediately achievable vs. long-term achievements.

Much prefer we put forward statewide clean indoor air vs. marketing strategy.

I agree.

I don't think these are mutually exclusive. Move forward with what's achievable now.

Are we after a bill or a law? (Semantic thing.)

Advocate no-compromise clean indoor air law along with achievable initiatives at the local level.

Next, move on to funding for implementing comprehensive tobacco control.

* Need for minimum level of funding recommending by CDC to include all 9 elements.
* Source of money - excise tax, master settlement agreement

On Master Settlement Agreement, if children's cabinet is looking at evaluating existing programs, is there a possibility that some of programs that have been funding through Master Settlement Agreement will be eliminated from mix and more available through reallocation?

Not sure.

Go back to Master Settlement Agreement for increased funding.

Include statement that funding should be consistent with CDC's $18 million.
Increase funding to best practices level.
At one point, recommendation was to step up in thirds.
Increase funding over time...
You have to articulate $18 million vs. 'optimal level'.

Any recommendations on source?
Well, most likely sources are...
- current and/or new excise tax
- Master Settlement Agreement
- state general funds (not likely)
- penalty tax for businesses (see recommendation below)

Do we need to prioritize these?
Whose funding are we taking if we use existing funding?

Excise - decreases use AND increases revenue

If had to make ONE funding recommendation, should be increased excise tax dedicated to comprehensive tobacco control.

Penalty tax on state income tax on any bus that don't have smoke-free grounds - incentives for businesses, plus it increases the revenue. Revenue towards tobacco free programs.

Smoke free grounds?

Can work on this...could do inside buildings, smoke-free grounds...incentives for people who are contributing to problem help contribute to solution to problem.

Also fits into recommendations about organization-level.

What if you gave establishments a tax break for, say, 1st two years after they go smoke free? Might be more palatable. Talking about incentive part of it. Anyone whose place currently a smoking establishment...if anyone is already smoke free, get 2-year tax break.

Con: this would take money away from current tax base.

Understand, but talking about positive, too - rewards for smoke-free.

1. Increase in excise tax with partial designated funding for comp tobacco control.
Why just partial?
Think you would have more support for 'partial'
Think a nickel would generate $5 million. (e.g., if increased to 55 cents, 5 cents would go to tobacco control)

Rational: Money spent on Medicaid…putting back money to general fund (related to Master Settlement Agreement)

Let's vote. These are the funding increase options for comprehensive tobacco control (move towards $18 million); what to recommend to S.C. as top priority:
1. Increase excise tax with at least partial increase directed to comprehensive tobacco control
2. Redirect master settlement agreement to tobacco prevention
3. Redirect existing excise tax to tobacco prevention
4. Penalty tax &/or incentives for businesses to enact clean indoor air

We don't have to prioritize, do we?

Above seems like a logical priority.

Also, S.C. will re-discuss and re-prioritize anyway.

Incentives for business kind of an in-kind contribution in reaching your goal. Either get what you want (lower smoking rates) through policy or get what you want (lower smoking rates) through $ for comprehensive tobacco control.

Have penalties or incentives for businesses been proposed elsewhere?

Also had discussion about articulating need. Cost/benefit. (Let's discuss with recommendation III.)

On to Recommendation III from Meeting 1 notes. Organizational-level policies.

Another one came up today - incentives for schools to enact smoke-free groups.

Hospitals - yes, Kansas Hospital Association (KHA) has a plan, a model policy, and timeline. All hospitals have their own timeline. Various ones at various times. It's underway. KHA is putting a lot of their influence behind it. A lot will end up falling on the shoulders of the medical staff. Possibility of losing employees to hospitals in border towns (concern of hosp.). Rolling out now.

Is there anything underway to extend to private physician offices?

Not sure. Maybe Kansas Medical Society is working on this; could ask them.

Think state law prohibits in all medical facilities (doctor’s offices)

KHA serves as a model for this, but thinking of all organizations.

28-30 organizations on S.C. Challenge: each of them working towards smoke-free grounds in their organizations.

Yes, move this one forward (all org).

What about policy of not hiring smokers?

There are businesses that do this.

Recommend NOT move this one forward.

Quitline. Actual call bank is out of state. Have about 500 people calling per month.

Blue Cross Blue Shield has link off website to Quitline.

Wouldn't this be as part of preventive care that they would refer to KS Quitline?

KS Quitline would be PART of preventive package.

Best treatments are individualized. Some patients may not be ready to use. Offering in every case is feasible, but not possible for ALL to be referred.

How would we encourage or get incentives for medical, doctor offices to make it their practice to use Quitline?

Better reimbursement to assist with the whole effort of prevention. Quitline won't do everything for everyone who smokes, but a good starting place. Some sort of reimbursement available for cessation counseling.

Actually, for some categories of points, there is reimbursement available for providing counseling. If you go beyond counseling, that's programs give people a range of options, including Quitline.

Most patients are not covered...

Medicare, Medicaid...fairly limited...if you spend the amount of time you need to, will exceed the payment threshold.

Need coverage by insurance companies for tobacco cessation.

Hard to get adequate reimbursement for preventive measures that make so much difference in people's health.

Hear over and over from physician - my time is limited, if you won't pay me for my time, I can't afford to give it to you.

Right now, we pay the doctor to consult with a patient on anything he needs to consult with them on - it's called an office visit.

So if coded as tobacco use control, will be reimbursed same as for, say, diabetes?

Office visits are coded based on time spent with patients. We don't deny office visits.

Aren't based on diagnostic codes?

To my knowledge, if something is coded...if counseling for tobacco usage, probably also counseling for health, or their heart.

This is the strategy used in the past. Have to charge to say, heart disease, rather than tobacco cessation because can't get reimbursement for tobacco cessation diagnostic code.

I would assume that office visits are office visits. e.g., routine physical

Yes, but physicals are health procedures.

Have heard from providers that they’re not getting reimbursed for the time spent for tobacco cessation.

Will check for sure on industry standards.

Yes, but if someone comes in for routine counseling...

Perception of providers, time spent on cessation counseling not reimbursable - or not as reimbursable - as high blood pressure, diabetes, etc.

Leave on and pursue this.

Not sure about dental office.

Medicaid, lack of reimbursement for tobacco cessation, inadequate level.

Smoking cessation classes, patches, etc. not cost effective (from industry perspective) because they are not successful. If proven to be successful, insurance companies would do. Even if you pay for it 2-3 times, people will go back to smoking.

Disagree with firmly. Cost/benefit data shows if treat every patient who is a smoker, more cost effective than treating moderate high blood pressure.

Something we need to look into in theory.

Can we look at something broader? Providers and dentists know about Quitline, give out cards. Ask them to do minimal level as a goal. Providers know it exists, able to pass info along easily.

Is there a prescribed amount of counseling?

If all providers have to do is advise and hand someone a card, very open to this because it saves them time. Unfortunately, not the optimal treatment for every patient.

Need to make sure they all know about Quitline.

Are we comfortable with the recommendation in section III?
What we're doing is recommending that these are changes to S.C.

Paula reviewed...
III.D. Incorporate economics of tobacco into all reports.
III.E & F. Smoke free, Chambers of Commerce.

For our annual meeting, not aware of a total smoke-free facility. Plus, booked about 3 years out.
Kind of a chicken & egg issue.

When we go into a conference center and hold a meeting, insist that it be smoke-free while we're there.

Not sure about the phrasing on this recommendation.

Challenges with what's already scheduled.

Looking to have economic impact, leverage on local level.

Wording change: Insist on smoke-free environments for publicly held meeting (but not imply that the communities other than Lawrence are ineligible).
Or, change to 'smoke-free facilities'.

A lot of places will declare facility smoke-free if groups request it.

They do try to be accommodating for those types of requests.

Discussion on specifying publicly-funded needs to be smoke-free. Yes, want that, but also want to include private, not-for-profit organizations in this.

Yes, include IV. Didn't talk about how to do this.
Tobacco Free Kansas Coalition (TFKC) has pulled together last 7 communities that have enacted relatively effective smoke-free ordinances.
TFKC also has...quick telephone survey of existing smoke-free grounds policy for school districts.

Yes, include incentives for schools to have smoke-free grounds.

Under III (organization level), need something that pertains to retailer sales and law enforcement. Encouragement for local businesses to fully comply with youth access laws, minimum age of sales of tobacco products. Encourage law enforcement to fully enforce.

Next, will compile discussion results for S.C. Will be presented to S.C. on Dec 16th.

Will post recommendations on the website. Will also provide feedback of S.C. response.

Meeting 2 Discussion Board is now closed. Please add additional comments to the General Discussion Board.
Is anyone on the phone that we haven't captured in the participant's list?
I have info on a survey done in Wichita in Oct. 2003. 65% said they would support a local ordinance in your community that would prohibit smoking in most indoor public places, including workplaces, public buildings, restaurants, and bars. Carolyn
Please post questions or comments here.
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